Information Collection

Submit a Complaint - Small Business Intake User Experience Test

IC 224862 under ICR 201504-3170-002 · OMB 3170-0042.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3170-0042 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Information Sheet.pdf	Other-Information
Moderator Guide.pdf	Other-Moderator's Guide
Consumer Response - Small Business Intake Screener.pdf www.forsmarshgroup.com	Form and Instruction
IC Template 3170-0042.pdf IC Template - 3170-0042	IC Document

IC Title:

Submit a Complaint - Small Business Intake User Experience Test

Agency IC Tracking Number:

DI00459

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Information			Information Sheet.pdf		Yes	No	Printable Only
Other-Moderator's Guide			Moderator Guide.pdf		Yes	No	Printable Only
Form and Instruction	NA	Consumer Response - Small Business Intake	Screener.pdf	www.forsmarshgroup.com	Yes	Yes	Fillable Fileable

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records

Title: CFPB.005 Consumer Response System

FR Citation: 79 FR 2144

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	159	159
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
IC Template - 3170-0042	IC Template 3170-0042.pdf	12/15/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.